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Infant deaths in Samoa a tragic outcome from error preparing MMR vaccine

The deaths of two infants on 6 July 2018 in Samoa shortly after receiving their MMR immunisations were under investigation by the Samoan Ministry of Health and Samoan Police. However, the inquest was put on hold until the trial of the two nurses who administered the MMR vaccines had been completed. 

On 4 June 2019, both nurses pleaded guilty to negligence causing manslaughter. On 2 August, both nurses were sentenced to five years in prison. During the sentencing hearing, it was confirmed that one of the nurses mixed the MMR vaccine powder with expired muscle relaxant anaesthetic instead of water for injection supplied in a vial with the vaccine. Eight Samoan speaking New Zealand nurses visited Samoa in June to provide training for vaccinating nurses at district hospitals.

There have also been media reports of two other deaths of Samoan siblings on separate occasions more than a week after MMR vaccination – these deaths occurred in 2017 and April 2018. A very rare genetic immune disorder is expected to have contributed to the death of the second sibling, who died in New Zealand. It is suspected that the first sibling had the same disorder. The family are undergoing genetic testing.

We would like to acknowledge the tragic losses experienced by the families of these infants, and concerns of the communities both in Samoa and in New Zealand.

The following has been updated as more information on the events on 6 July 2018 came to hand.

MMR is a vaccine given after one year of age to protect against three diseases; measles, mumps and rubella.

  • MMR vaccines have been used for decades all over the world including New Zealand and there is a long track record of safety.
  • The vaccine used in New Zealand and Samoa is extremely safe.
  • There has never been a death associated with the administration of this vaccine in New Zealand.

Rarely a tragic event such as the one on 6 July in Samoa occurs. There are two main reasons why something like this might happen:

  • Medical error, where the vaccine is prepared for injection incorrectly and the wrong substance is injected. This is what was found to have occurred, expired muscle relaxant anaesthetic was mixed with the MMR vaccine powder instead of water for injection supplied in a vial with the vaccine
  • Contamination of the vaccine due to leaving it at room temperature for a long period of time.

At the request of the Samoan Ministry of Health, the World Health Organization has mobilised an immunisation expert from the Western Pacific Regional Office to assist with the investigation and a forensic pathology team from Melbourne, Australia, to support the Government in the forensic work that will contribute to the evaluation of what caused these events. 

The MMR vaccine used in Samoa is a five-dose vial. The batch lot of the vaccine administered to these two children has been in use in Samoa since August 2017 with no safety concerns. The same batch lot is also in use in a number of South American and Caribbean countries, including Belize, Ecuador, St. Vincent, Trinidad Tobago, Chile, Aruba, Dutch Antilles, St. Kitts & Nevis and Cuba, with no reports of adverse events.   

Click on the link to read the New Zealand Ministry of Health statement on the investigation into MMR vaccine safety in Samoa

August 9th, 2018

News reports have indicated that a nurse has been charged by Samoan police in relation to the deaths of the two infants on 6 July 2018. The nature of the charges will be made known at a hearing planned for the 14th of August. The coronial inquest for the two infants has been deferred until 12 September 2018 whilst authorities await the infant's full post-mortem reports. 

August 14th, 2018

The first court hearing of the nurse charged in relation to the deaths was held today. She was charged with manslaughter, negligence and perverting the course of justice after the children died after being given the measles, mumps and rubella (MMR) vaccine. Visit the newshub story here.

August 15th, 2018

A second nurse in Samoa has been charged with manslaughter in relation to the deaths of the two children. Both nurses are due to appear in the Samoa Supreme Court on 27 August 2018.

August 24th, 2018

Report on RNZ website: Samoa's Prime Minister has called for nurses to be well trained, in light of last month's deaths of two babies after they received the MMR vaccine. Tuila'epa Sa'ilele Malielegaoi said the post mortem preliminary report did not find anything wrong with the vaccine but human error seemed to be involved in the diluting of the vaccine. 

September 14th, 2018

The Commission of Inquiry into the deaths of the infants commenced on 12th September. After hearing from the Samoan National Health Services, Ministry of Health and School of Nursing, the Commission highlighted the need for ongoing nurse training during their employment in the health sector. The Inquiry was adjourned on 14th September until after the Court proceedings against the two nurses charged with the manslaughter of the infants are concluded. The hearings are due to commence in February 2019.

November 20th 2018

Report on RNZ website: MMR vaccine is now being given again, and vaccination procedures revised and tightened. Minister of Health in Samoa, Tuitama Dr Leao Tuitama, responded to questions from the Samoa Observer "We have a new rigorous approach to assure the mistakes of the past will not be repeated."

March 27th 2019

Report on RNZ website: the Samoa Supreme Court trial of the two nurses involved in the administration of the MMR vaccine doses has been delayed until June 2019. The defence lawyer for the nurses has not received reports from the post-mortems conducted in Samoa and overseas, or information from the overseas investigation into the cause of the children's deaths. 

June 5th 2019

Report on RNZ website: the two nurses in Samoa, facing charges over the deaths of two babies, have pleaded guilty to manslaughter. They will be sentenced on 18 June.

June 6th 2019

Report on RNZ website: Samoa's health ministry says the deaths of two babies last year were caused by nurses mixing the wrong liquid with MMR vaccines. Eight New Zealand nurses will go to Samoa this month to re-train all vaccinating nurses.

June 17th 2019

Report on Samoa Global News website: sentencing of the two nurses facing charges over the deaths of two babies has been adjourned.

June 18th 2019

Report on RNZ website: A team of New Zealand nurses have arrived in Samoa for a 10-day mission to re-train all vaccinating nurses.

July 12th 2019

Report on the Global Advisory Committee on Vaccine Safety (GACVS) meeting 5–6 June 2019: GACVS is an independent expert clinical and scientific advisory body, provides WHO with scientifically rigorous advice on vaccine safety issues of potential global importance. A GACVS subgroup on vaccine safety communication studied selected vaccine communication crises, including that associated with Dengvaxia in the Philippines, measles, mumps and rubella (MMR) vaccine in Samoa and Sudan, and HPV vaccine in five countries. A review of the case studies demonstrated that crises can be mitigated when key stakeholders are involved and proactive communications are established immediately. In Samoa (MMR), there was prompt communication among the relevant authorities and appropriate investigations, but initial attempts to hide the vaccination error and blaming individuals rather than conducting systemic analyses were detrimental to the vaccine programme. The public was not informed of the reasons for the event. The subgroup highlighted that appropriate, timely communication with the public is of paramount importance.

July 15th 2019

Report on RNZ website: The sentencing of two nurses in Samoa, relating to the deaths of two infants after receiving the MMR vaccine, has again been delayed. The case has been adjourned until 2 August as the defence lawyer was engaged in another matter.

August 3rd 2019

Report on RNZ website: The two nurses, who pleaded guilty to negligence causing the manslaughter of two infants, have been sentenced to five years in prison. 

The Samoa Observer published a detailed acount of the sentencing hearing, where it was confirmed that one of the nurses mixed the MMR vaccine powder with expired muscle relaxant anaesthetic instead of water for injection supplied in a vial with the vaccine.

Last updated: Jan 2020